Does operative time affect infection rate in primary total knee arthroplasty?

BACKGROUND: Prolonged operative time may increase the risk of infection after total knee arthroplasty (TKA). Both surgeon-related and patient-related factors can contribute to increased operative times. QUESTIONS/PURPOSES: The purpose of this study was to determine (1) whether increased operative time is an independent risk factor for revision resulting from infection after TKA; (2) whether increasing body mass index (BMI) increased operative time; and (3) whether increasing experience substantially decreased operative time. METHODS: We retrospectively evaluated primary TKAs from our joint registry between March 2000 and August 2012. Cox proportional hazard models were used to assess the relationship between operative time and revision resulting from infection after accounting for age, sex, BMI, and Agency for Healthcare Research and Quality comorbidity score. Of 9973 instances of primary TKA, 73 underwent revision surgery for infection (0.73%). RESULTS: After accounting for the confounders of age and sex, operative time was not found to have a significant effect; a 15-minute increase in operative time increased the hazard of revision resulting from infection by only 15.6% (p=0.053; 95% confidence interval, 0.0%-34.0%). In addition, a five-unit increase in BMI was found to increase mean operative time by 1.9 minutes, on average, regardless of sex (p<0.0001). Operative time decreases with increasing experience but appears to plateau at approximately 300 surgeries. CONCLUSIONS: Operative time is only one of many factors that may increase infection risk and may be influenced by numerous confounders. Increasing BMI increased operative time but the effect was modest. The effect of increasing experience on operative duration of this common procedure was surprisingly limited among our surgeons. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Comparative effectiveness of ceramic-on-ceramic implants in stemmed hip replacement: a multinational study of six national and regional registries.

BACKGROUND: The rapid decline in use of conventional total hip replacement with a large femoral head size and a metal-on-metal bearing surface might lead to increased popularity of ceramic-on-ceramic bearings as another hard-on-hard alternative that allows implantation of a larger head. We sought to address comparative effectiveness of ceramic-on-ceramic and metal-on-HXLPE (highly cross-linked polyethylene) implants by utilizing the distributed health data network of the ICOR (International Consortium of Orthopaedic Registries), an unprecedented collaboration of national and regional registries and the U.S. FDA (Food and Drug Administration). METHODS: A distributed health data network was developed by the ICOR and used in this study. The data from each registry are standardized and provided at a level of aggregation most suitable for the detailed analysis of interest. The data are combined across registries for comprehensive assessments. The ICOR coordinating center and study steering committee defined the inclusion criteria for this study as total hip arthroplasty performed without cement from 2001 to 2010 in patients forty-five to sixty-four years of age with osteoarthritis. Six national and regional registries (Kaiser Permanente and HealthEast in the U.S., Emilia-Romagna region in Italy, Catalan region in Spain, Norway, and Australia) participated in this study. Multivariate meta-analysis was performed with use of linear mixed models, with survival probability as the unit of analysis. We present the results of the fixed-effects model and include the results of the random-effects model in an appendix. SAS version 9.2 was used for all analyses. We first compared femoral head sizes of >28 mm and ≤28 mm within ceramic-on-ceramic implants and then compared ceramic-on-ceramic with metal-on-HXLPE. RESULTS: A total of 34,985 patients were included; 52% were female. We found a lower risk of revision associated with use of ceramic-on-ceramic implants when a larger head size was used (HR [hazard ratio] = 0.73, 95% CI [confidence interval] = 0.60 to 0.88, p = 0.001). Use of smaller-head-size ceramic-on-ceramic bearings was associated with a higher risk of failure compared with metal-on-HXLPE bearings (HR = 1.36, 95% CI = 1.09 to 1.68, p = 0.006). Use of large-head-size ceramic-on-ceramic bearings was associated with a small protective effect relative to metal-on-HXLPE bearings (not subdivided by head size) in years zero to two, but this difference dissipated over the longer term. CONCLUSIONS: Our multinational study based on a harmonized, distributed network showed that use of ceramic-on-ceramic implants with a smaller head size in total hip arthroplasty without cement was associated with a higher risk of revision compared with metal-on-HXLPE and >28-mm ceramic-on-ceramic implants. These findings warrant careful reflection by regulatory and clinical communities and wide dissemination to patients for informed decision-making regarding such surgery.

Efficacy of revision surgery for the dislocating total hip arthroplasty: report from a large community registry.

BACKGROUND: Historically, achieving stability for the unstable total hip arthroplasty (THA) with revision surgery has been achieved inconsistently. Most of what we know about this topic comes from reports of high-volume surgeons' results; the degree to which these results are achieved in the community is largely unknown, but insofar as most joint replacements are done by community surgeons, the issue is important. QUESTIONS/PURPOSES: We used a community joint registry to determine: (1) the frequency of repeat revision after surgery to treat the unstable THA; (2) what surgical approaches to this problem are in common use in the community now; (3) are there differences in repeat revision frequency that vary by approach used; and (4) has the frequency of repeat revision decreased over time as surgical technique and implant options have evolved? METHODS: We reviewed 6801 primary THAs performed in our community joint registry over the last 20 years. One hundred eighteen patients (1.7%) with a mean age of 67 years were revised within the registry for instability/dislocation. Failure was defined as a return to the operating room for rerevision surgery for instability. Minimum followup was 2 years (average, 9.4 years; range, 2-20 years) with six patients having incomplete followup. The frequency of rerevisions was calculated and compared using Pearson's chi-square test. Cumulative rerevision rates were calculated using the Kaplan-Meier method and types of revision procedures were compared using the log-rank test. RESULTS: The initial revision procedure was successful in 108 patients (92%); 10 patients underwent repeat surgery for recurrent dislocation after their initial revision surgery. The most frequently performed procedure was revision of the head and liner only (35 of 118 [30%]); constrained devices were used in 19% (22 of 118) of the procedures. There was no difference in the cumulative rerevision rates for instability or dislocation by type of revision procedure performed. Six of 22 constrained liners were rerevised for varying indications. There was no difference in frequency of repeat revision for instability between those patients revised for THAs performed before 2003 and those managed more recently. CONCLUSIONS: Revision surgery for unstable THA is successfully managed in the community with a variety of surgical interventions. Identifying the reason for dislocation and addressing the source remain paramount. Constrained liners should be used with caution; although typically used in the most problematic settings, rerevision for a variety of failure modes remains troublesome. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Getting on with living life: experiences of older adults after home care.

Providers in all settings are increasingly aware of the need to focus on transitional care needs and services across healthcare settings to improve quality of life, maintain optimal health, and prevent unnecessary hospitalizations. Home care is an essential piece of the transitional care puzzle, especially in providing services to support older adults with chronic comorbid conditions to remain at home safely with optimal health and psychosocial well-being. Home care is essential in bridging the gap from acute hospital care to home; however, little is known about the needs of older adults after discharge from home care. Our study investigated the perceptions of older adults with chronic health conditions after discharge from home care regarding their daily activities and healthcare needs and identified how these needs were met.

Improved survival of uncemented versus cemented femoral stems in patients aged < 70 years in a community total joint registry.

BACKGROUND: Aseptic loosening of the femoral stem remains a significant reason for revision in total hip arthroplasty (THA). Although stem fixation methods have changed over time, there is relatively little evidence supporting cemented or uncemented stems as more durable constructs. QUESTIONS/PURPOSES: We examined whether there was a difference in survival to revision between cemented and uncemented THA stems (1) for any reason; (2) for aseptic loosening or loosening related to wear/osteolysis; (3) based on patient age groupings (as a proxy for patient activity level); and (4) based on procedural timeframe groupings between cemented and uncemented stems. METHODS: A total of 6498 primary cemented and uncemented THAs were registered in our community total joint replacement registry between 1991 and 2011. Analysis was performed to compare age, sex, procedural timeframe, and diagnosis for both groups. Our primary outcome was revision of the stem component for aseptic loosening or loosening secondary to wear/osteolysis. Analyses were done using Wilcoxon rank sum tests, Pearson's chi-square tests, Kaplan Meier methods, and Cox regression. RESULTS: After adjusting for age, sex, primary diagnosis, and procedural timeframe as confounders, cemented femoral stem components were 1.63 times as likely as uncemented stems to be revised for any reason (p = 0.02) and 3.76 times as likely as uncemented stems to be revised for aseptic loosening or loosening related to wear/osteolysis (p < 0.001). When grouped by age, specifically in regard to revisions for aseptic loosening or loosening related to wear/osteolysis, uncemented stems had lower cumulative revision rates in patients aged < 70 years (p < 0.001) compared with cemented stems. There was a trend away from cemented fixation in our registry, which shifted from over 80% cemented stem use in 1996 to 3% in 2011. CONCLUSIONS: We found that uncemented stems were associated with fewer revisions for aseptic loosening in patients < 70 years old, but when all reasons for revision were considered, neither group demonstrated superior survival. With a mean followup of 6.5 years, longer followup is needed to verify these results over time.

Cumulative revision rate is higher in metal-on-metal THA than metal-on-polyethylene THA: analysis of survival in a community registry.

BACKGROUND: Metal-on-metal (MOM) THA bearing technology has focused on improving the arc of motion and stability and minimizing wear compared with traditional metal-on-polyethylene (MOP) bearing couples. It is unclear whether this more costly technology adds value in terms of improved implant survival. QUESTIONS/PURPOSES: This study evaluated Kaplan-Meier survival, revisions for dislocation, and cost of MOM THA compared with metal-on-cross-linked polyethylene (MOXP) THA in a community joint registry, with subset analysis of the recalled Depuy ASR™ implant. METHODS: All MOM THAs (resurfacings excluded) performed between January 2002 and December 2009 were included (n = 1118) and compared with a control group of MOXP THAs (n = 1286) done during the same time. Analysis was performed to compare age, gender, cost of implant, length of stay, year of index procedure, diagnosis, head size (< 32 mm versus ≥ 32 mm), revision and revision reason for both groups. Analysis at a mean of 3.6 years was done using Wilcoxon rank sum tests, Pearson's chi-square tests, Kaplan Meier methods, and Cox regression. RESULTS: The cumulative revision rate (CRR) was higher in MOM implants than in MOXP implants (MOM CRR = 13%; MOXP CRR = 3%). MOM implants were three times as likely to be revised as MOXP implants after adjustment for age, head size, and year of procedure. The recalled DePuy ASR™ implant was six times as likely to be revised as other MOM THAs. After removing the ASR™ implants from analysis, survivorship of MOM implants was not better than that of the MOXP hips. CONCLUSIONS: During the study time, MOM THAs showed inferior survival to MOXP THAs after adjusting for age, head size, and year of procedure. Longer followup is necessary to see whether MOM THAs add value in younger patient groups.

Developing a personal health record for community-dwelling older adults and clinicians: technology and content.

To empower older consumers and improve health outcomes, a consumer-friendly personal health record (PHR) is needed. The purpose of this article was to evaluate PHR technology and content for older community-dwelling consumers. Specific aims were to: (a) develop a secure, web-based application for a PHR to enable interoperable exchanges of data between consumers and clinicians; (b) develop structured, evidence-based shared care plan content for the PHR using an interface terminology standard; and (c) validate the shared care plans with consumers. An interoperable web-based form was developed. The standardized PHR content was developed by expert panel consensus using the Omaha System problem list and care plans, and validated by consumer interviews. Evidence-based shared care plans for 21 problems common among community-dwelling older adults were developed and encoded with Omaha System terms for data capture in the PHR. An additional problem, Neighborhood-workplace safety, was identified by consumers and will be added to the care plans.

Revision surgery for patellofemoral problems: should we always resurface?

BACKGROUND: Routine patellar resurfacing performed at the time of knee arthroplasty is controversial, with some evidence of utility in both TKA (tricompartmental) and bicompartmental knee arthroplasty. However, whether one approach results in better implant survival remains unclear. QUESTIONS/PURPOSES: We asked whether (1) routine patellar resurfacing in TKAs resulted in lower cumulative revision rates compared to bicompartmental knee arthroplasties, (2) patella-friendly implants resulted in lower cumulative revision rates than earlier designs, and (3) bicompartmental knee arthroplasties revised to TKAs had higher cumulative revision rates than primary TKAs. PATIENTS AND METHODS: From a community-based joint registry, we identified 8135 patients treated with 9530 cemented, all-polyethylene patella TKAs and 627 bicompartmental knee arthroplasties without patellar resurfacing. We compared age, gender, year of index procedure, diagnosis, cruciate status, revision, and revision reason. RESULTS: TKAs had a lower cumulative revision rate for patella-only revision than bicompartmental knee arthroplasties (0.8% versus 4.8%). Adjusting for age, bicompartmental knee arthroplasties were 6.9 times more likely to undergo patellar revision than TKAs. There was no difference in the cumulative revision rate for patella-only revisions between patella-friendly and earlier designs. The cumulative revision rate for any second revision after a patella-only revision was 12.7% for bicompartmental knee arthroplasties while that for primary TKAs was 6.3%. CONCLUSIONS: Bicompartmental knee arthroplasties had higher revision rates than TKAs. Femoral component design did not influence the cumulative revision rate. Secondary patella resurfacing in a bicompartmental knee arthroplasty carried an increased revision risk compared to resurfacing at the time of index TKA. To reduce the probability of reoperation for patellofemoral problems, our data suggest the patella should be resurfaced at the time of index surgery.

Do "premium" joint implants add value?: analysis of high cost joint implants in a community registry.

BACKGROUND: Numerous joint implant options of varying cost are available to the surgeon, but it is unclear whether more costly implants add value in terms of function or longevity. QUESTIONS/PURPOSES: We evaluated registry survival of higher-cost "premium" knee and hip components compared to lower-priced standard components. METHODS: Premium TKA components were defined as mobile-bearing designs, high-flexion designs, oxidized-zirconium designs, those including moderately crosslinked polyethylene inserts, or some combination. Premium THAs included ceramic-on-ceramic, metal-on-metal, and ceramic-on-highly crosslinked polyethylene designs. We compared 3462 standard TKAs to 2806 premium TKAs and 868 standard THAs to 1311 premium THAs using standard statistical methods. RESULTS: The cost of the premium implants was on average approximately $1000 higher than the standard implants. There was no difference in the cumulative revision rate at 7-8 years between premium and standard TKAs or THAs. CONCLUSIONS: In this time frame, premium implants did not demonstrate better survival than standard implants. Revision indications for TKA did not differ, and infection and instability remained contributors. Longer followup is necessary to demonstrate whether premium implants add value in younger patient groups. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The efficacy of healing touch in coronary artery bypass surgery recovery: a randomized clinical trial.

CONTEXT: The use of complementary therapies in conjunction with conventional care has great potential to address patient pain, complication rates, and recovery time. Few studies of such therapies have been conducted in hospital settings where some of the most stressful procedures are performed on a regular basis. OBJECTIVE: We hypothesized that patients receiving healing touch (HT) would see improved outcomes. DESIGN: Patients were randomized into 1 of 3 treatment groups: no intervention, partial intervention (visitors), and an HT group. SETTING: This study was conducted in an acute-care hospital in a large metropolitan area. PATIENTS OR OTHER PARTICIPANTS: Patients undergoing first-time elective coronary artery bypass surgery were invited to participate. There were 237 study subjects. INTERVENTION: HT is an energy-based therapeutic approach to healing that arose out of nursing in the early 1980s. HT aids relaxation and supports the body's natural healing process. MAIN OUTCOME MEASURES: This study consisted of 6 outcome measures: postoperative length of stay, incidence of postoperative atrial fibrillation, use of anti-emetic medication, amount of narcotic pain medication, functional status, and anxiety. RESULTS: Analysis was conducted for all patients and separately by inpatient/outpatient status. Though no significant decrease in the use of pain medication, anti-emetic medication, or incidence of atrial fibrillation was observed, significant differences were noted in anxiety scores and length ofstay. All HT patients showed a greater decrease in anxiety scores when compared to the visitor and control groups. In addition, there was a significant difference in outpatient HT length of stay when compared to the visitor and control groups.

Registry outcomes of unicompartmental knee arthroplasty revisions.

UNLABELLED: Perceptions of the difficulty and outcome of unicompartmental knee arthroplasty revision (rev-UKA) vary. We analyzed differences in the complexity, cost, and survival of rev-UKAs compared with revision TKAs (rev-TKA). One hundred eighty knee arthroplasty revisions (68 rev-UKAs/112 rev-TKAs), defined as a minimum of tibial or femoral component revision, were identified from a community joint registry of 7587 knee implants performed between 1991 and 2005. Four of 68 rev-UKAs (5.9%) were revised a second time, whereas seven of 112 rev-TKAs (6.3%) were rerevised. Rev-TKA was predictably more complex than rev-UKA based on the proxies of operative time, use of modular augmentation and stems, and polyethylene liner thickness. Thirty-nine of 68 rev-UKAs (57%) had no form of augmentation and were revised as primary TKAs. There were more rev-TKAs than rev-UKAs with an implant cost greater than $5200 (42% versus 12%) and hospital charges greater than $33,000 (48% versus 25%). We found no difference in survival between the groups. Although rev-UKAs had less surgical complexity and bone loss at the time of revision compared with rev-TKAs, we were unable to show improved survival of rev-UKAs compared with rev-TKAs. Rev-UKAs were associated with lower implant costs and hospital charges compared with rev-TKAs. LEVEL OF EVIDENCE: Level II, prognostic study.

Knee arthroplasty in the young patient: survival in a community registry.

UNLABELLED: Operative options for the younger patient with an arthritic knee remain controversial. We prospectively followed 1047 patients 55 years old or younger who underwent knee arthroplasty in a community joint registry over a 14-year period. Patients were implanted with 1047 joints of three predominant designs by 48 surgeons in four hospitals associated with a community joint registry. The mean age for this cohort was 49.8 years, and 62.8% (657/1047) of the patients were female. There were a total of 73 revisions performed, 5.6% (37/653) in women and 9.2% (36/394) in men. Cemented TKAs performed best, with a cumulative revision rate of 15.5%, compared to 32.3% in unicompartmental knee arthroplasty (UKA) patients and 34.1% in cementless designs. Men had a higher cumulative revision rate than women, 31.9% compared to 20.6%. Adjusting for implant type and gender, there was no difference in cumulative revision rate based on diagnosis (OA versus other) or age group (< or = 40, 41-45, 46-50, 51-55 years) or between cruciate-retaining and -substituting designs. Eighty five percent of cemented TKA implants survived at 14 years in the population under 55 years of age in this community registry. Cementless designs and UKA increased revision risk independently. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Excellent survival of all-polyethylene tibial components in a community joint registry.

UNLABELLED: The advantages of the monoblock design and lower cost have prompted renewed interest in the all-polyethylene tibia in total knee arthroplasty. We prospectively followed patients with all-polyethylene tibial total knee arthroplasties over a 14-year period. Since 1991, 443 total knee arthroplasties using an all-polyethylene tibia component were implanted by 12 surgeons in four hospitals associated with a community registry. One of three designs was used in over 98% of cases. The mean age of the patient population was 77 years and 78% were female. Ninety-three patients died with their prosthesis intact. Three revisions were performed on this population with mean followup of 66.3 months (range, 0-158 months). Kaplan-Meier survival analysis revealed 99.4% survival at 14.3 years with revision for any reason as the end point. With aseptic loosening or wear as the revision reason, survival is 99.7% at 14.3 years. Total knee arthroplasty with one of the three contemporary congruent all-polyethylene tibia designs used in this registry performed extremely well in this population; savings for this group (compared to those with a metal-backed component) was estimated at $729 per case. If all patients older than 75 years of age in our registry had received an all-polyethylene tibia, the estimated savings for the implant alone would have been $1.28 million. LEVEL OF EVIDENCE: Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Why are total knee replacements revised?: analysis of early revision in a community knee implant registry.

Since 1991, 5760 knee arthroplasty procedures done by 53 surgeons have been registered in a community joint implant registry and were reviewed regarding initial revision done within the healthcare system. The 168 revisions done represented 2.9% of the knee arthroplasties between September 1991 and December 2002. Survival was defined as the absence of revision surgery. Death was considered a censored event. Cumulative survival rates for the different total knee arthroplasty configurations were: cemented total knee arthroplasty with all-polyethylene tibia, 99.2%; cemented total knee arthroplasty with metal-backed tibia, 96.3%; hybrid total knee arthroplasty, 89.3%; and unicondylar knee arthroplasty, 87.2%. Cemented total knee arthroplasty with metal-backed tibia had better survival than hybrid total knee arthroplasty, ingrowth total knee arthroplasty, and unicondylar knee arthroplasty. Cemented total knee arthroplasty with a metal-backed tibia did not have better survival than cemented total knee arthroplasty with an all-polyethylene tibia. Gender was not related to survival. Age was related to survival, with older patients' knees surviving longer. Aseptic loosening or wear was the cause of revision in 40.8% of patients having total knee arthroplasty and 46.6% of patients having unicondylar knee arthroplasty, whereas progression of arthritis necessitated unicondylar knee revision in 51.2% of patients having that procedure. This study presents further evidence of the value of and ongoing need for total joint registries. Cemented total knee arthroplasty with all-polyethylene tibia and with metal-backed tibia showed more than 95% 10-year cumulative survival. Hybrid total knee arthroplasty, ingrowth total knee arthroplasty, and unicondylar knee arthroplasties did not show such good results.

Analysis of unicompartmental knee arthroplasty in a community-based implant registry.

Using a unique community implant and explant registry, long-term survival of unicompartmental knee arthroplasty was examined and compared with total knee arthroplasty (TKA) survival. All patients with unicompartmental knee arthroplasties done since September 1, 1991 were followed up prospectively to January 31, 2002 to assess survival and reason for revision. Five hundred sixteen unicompartmental knee arthroplasties of nine different designs were done by 23 surgeons. During this period, 39 of the 516 unicompartmental knee arthroplasties were revised. The major revision reasons for unicompartmental knee arthroplasties were progression of arthritis in the uninvolved compartments (51.3%), aseptic loosening (25.6%), and PE wear (20.5%). Kaplan-Meier survival analysis with revision as the end point revealed survival of 92.6% (range, 90.0%-95.2%) at 5 years for these unicompartmental knee arthroplasties and 88.6% (range, 85.0%-92.2%) at 10 years, compared with 94.8% (range, 93.5%-96.0%) at 10 years for primary TKAs. This community registry experience may more accurately reflect the results obtained in community practice, with different surgeons, varying indications, and numerous designs. The current study showed that revision of unicompartmental knee arthroplasties is done most commonly for progression of arthritis in the contralateral compartment, and at a higher rate than revision of primary cemented TKA.

Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons.

OBJECTIVE: To understand better the barriers among orthopedic surgeons and primary care physicians in identifying and treating possible osteoporosis in patients hospitalized with a fragility fracture sustained spontaneously or from a fall no greater than standing height. METHODS: A 1-page, 7-question survey was sent to 35 admitting orthopedic surgeons and 75 primary care physicians at a midwestern managed care organization in March 2001. Returned surveys were collected until 30 days had passed since the mailing. Primary care physicians were board-certified family practitioners and internal medicine physicians. All orthopedists were admitting surgeons in the hospital system. Responders were anonymous, and posted surveys were returned to the Orthopaedic Collaborative Practice office. The surveys were color-coded to separate responses from orthopedic surgeons and primary care physicians. RESULTS: Thirty-one surveys were returned: 23 (31%) from primary care physicians and 8 (23%) from orthopedic surgeons. Survey respondents agreed that the responsibility for postfracture attention to nutritional needs, including calcium and vitamin D, rested with the primary care provider. When asked about barriers to recommending bone mineral density testing with dual energy x-ray absorptiometry, 9 primary care physicians (39%) thought this type of testing was unnecessary for treatment, and 4 primary care physicians (17%) thought a barrier was caused by patient frailty. Primary care physicians indicated that potential adverse effects of medication (n=14 [61%]) and cost of therapy (n=13 [57%]) were the main factors limiting treatment. When asked to identify the single most important barrier in treatment, 14 physicians (61%) indicated cost was the greatest deterrent. Twenty-one primary care physicians (91%) reported they would be more likely to treat a patient with osteoporosis if a safe medication with proven fracture risk reduction were available. Primary care physicians indicated they were more likely to treat independently living adults (n=12 [52%]) and women compared with men (n=15 [65%]). All orthopedic surgeons (n=8) were willing for all patients to be evaluated in consultation with a nurse practitioner. Primary care respondents were less apt to agree with a nurse practitioner referral (n=5 [22%]). Both primary care physicians (n=16 [70%]) and orthopedic surgeons (n=4 [50%]) agreed that there is a need for increased primary care education about managing osteoporosis in patients hospitalized with low-impact fracture. CONCLUSIONS: Orthopedic surgeons were consistent in their opinion that postfracture attention to osteoporosis should rest with the primary care physician. Primary care physicians agree but report that cost and possible adverse effects of medication are major barriers to this care. Despite therapies for high-risk postfracture patients showing relative safety and proven efficacy in reducing future fractures, deterrents to this care are focused on cost and potential adverse effects. Further education is needed to promote a standard of care for the postfracture patient that is directed toward the prevention of a subsequent fracture.